Canoeing Icon Oscar Chalupsky Takes on Discovery Health in Pivotal Cancer Treatment Coverage Dispute

Key Takeaways

• A landmark ruling is expected in a case that could change how medical schemes pay for multiple myeloma cancer treatments in South Africa.
• The case involves 62-year-old Oscar Chalupsky, a well-known sportsman, who is fighting against Discovery Health Medical Scheme, the largest medical aid in the country.
• Chalupsky was diagnosed with multiple myeloma in 2019 and was prescribed the cancer drug Daratumumab, which the medical scheme only partially paid for.
• The Council for Medical Schemes ruled in favor of Chalupsky, finding that the medical scheme should have paid for the treatment in full, but Discovery has appealed the ruling.
• The case has highlighted the need for medical schemes to revise their funding models to align with the demands and costs of modern patient care.

Introduction to the Landmark Case
A landmark ruling is in the offing that could clear a path to compel medical schemes to revise how they pay for multiple myeloma cancer treatments that schemes have until now declined, or approved but with burdens of hefty co-payments for patients. The case involves 62-year-old Capetonian Oscar Chalupsky, a well-known sportsman, who is fighting against Discovery Health Medical Scheme, the largest medical aid in the country. Chalupsky is a 12-time Molokai Challenge surfski champion, multiple winner of the Umkomaas River Canoe Marathon, and represented South Africa in the 1992 Barcelona Olympics.

The Fight for Cancer Treatment Funding
The case has centered around the funding of a cancer drug called Daratumumab (Darzalex) that Chalupsky needed as his cancer progressed. Chalupsky was diagnosed in 2019 with multiple myeloma, a blood cancer that affects plasma cells. According to the Council for Medical Schemes, prescribed minimum benefits are a set of “essential healthcare services that all registered medical schemes are legally required to cover, regardless of the specific plan chosen. This ensures all members have access to continuous care for serious conditions.” Chalupsky started his treatment in June 2020, and three years later, his maintenance cancer therapy failed, and he suffered recurrent relapses. His doctor put him on Daratumumab because of his prior treatments and complications.

The Ruling and Appeal
While the medical scheme approved the prescription, it only paid 50% of the costs, leaving Chalupsky to lean on friends and family to help make up a shortfall of nearly R300,000. With the support of the NGO Campaigning for Cancer, Chalupsky lodged a complaint with the Council for Medical Schemes. His counsel argued that his treatment with the use of Daratumumab was medically justified and should have been paid in full in accordance with prescribed regulations. Discovery argued that Chalupsky’s treatment didn’t follow their sequencing of treatment for his type of cancer, and that skipping to Daratumumab did not constitute prescribed minimum benefit treatment. The Council for Medical Schemes disagreed and ruled in favor of Chalupsky, finding that had his physician followed Discovery’s treatment protocol and used the drug listed for next use, it would have been ineffective or caused Chalupsky harm.

The Impact of the Case
The case has highlighted the need for medical schemes to revise their funding models to align with the demands and costs of modern patient care. According to a study by actuaries and public health experts and actuaries at the Universities of Cape Town and Witwatersrand, breast, cervical, prostate, lung, haematological, and pediatric cancers are on the rise in South Africa. Their forecasts are that by 2030, there will be 121,000 incidents of cancer compared with 62,000 in 2019. The sobering truth is that a cancer crisis is coming, and medical schemes need to be prepared to handle the increased demand for cancer treatments. Lauren Pretorius from Campaigning for Cancer says that knowing this reality should be a wake-up call for medical schemes to revise their funding models.

Conclusion and Future Implications
The case is expected to be a turning point in the fight for cancer patients to receive fair and adequate treatment funding from medical schemes. Chalupsky and Campaign for Cancer are waiting for the final ruling, which is expected to be made in early 2026. The ruling could have far-reaching implications for medical schemes and cancer patients in South Africa. It is expected to raise awareness that cancer patients should have a clear idea of what they should be getting from their schemes, and it is also expected to prompt medical schemes to turn their attention to smarter funding that keeps them in business in the long run without penalizing their members. As Chalupsky says, “I have had hundreds of comments on my Facebook, Instagram, and LinkedIn over this case. I’m not a controversial person, but I am going to fight because there are so many people who are not as lucky as I am to have had people who have helped me to pay for treatment.”